HomeMy WebLinkAbout0002 BLACKBERRY LANE - HEALTH 2`'"BLA'CKBERRRY ;:LANE; HYANNIS
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Comm. of Massachusetts Executive Office of Environmental Affairs
Department of Environmental Protection
ONE WINTER STREET,BOSTON MA 02108(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 2 Blackberry Lane Name of Owner:Michelle Maher
Hyannis,MA 02601 Address of Owner: SAME n —�Date of of Inspection:01/15/05 , .
Name of Inspector:Michael J.DiMaggio
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) F E B o 2005
Company Name: MJD�Ins ectfo�ns
Mailing Address: 15 Hane Road;Mashpee MA
Telephone Number: (508)685-9250 TOWN OF iaN,aVSTABLE
HEALTH DEPT.
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,
accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper
function and maintenance of on-site sewage disposal systems.The system:
X Passes -gip �ZS
Conditionally Passes
F her Evaluation by the Local Authority ARCEL
Fails n
Inspectors Signatu-e: Date: 0
The system Inspector shall submit a co o this �.tioneportto the Approving Authority(Board of Health or DEP)within thirty
(30)days of completing this inspection. fl ia system is a shared system or has a design floe of 10,000 gpd or greater,the inspector
and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The
original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS:
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9/2/98 REVISION Page 1 of I 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 2 Blackberry Lane,Hyannis VIA 02601 4.
Owner: Michelle Maher
Date of Inspection:01/15/05
INSPECTION SUMMARY: Check A, B, C, orD:
A. SYSTEM PASSES:
X I have not found any information which indicates that*any of the failure conditions described in 310 CMR 15.303 exist.Any
failure criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,
upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why
not.
The septic tank is metal,unless the owner or op:rator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
The septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank
Failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
Approved by.the Board of Health. 1
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Sewage backup or breakout or high static water.level observed in the distribution box is due to broken or obstructed pipe(si
Or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of
Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass
Inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 2 Blackberry Lane,Hyannis MA 02601
Owner: Michelle Maher
Date of Inspection:01/15/05
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to
protect the public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310CMR
15303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE
PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering wetland or salt marsh.
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2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC
HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and SAS and the SAS is within]00 feet of a surface water supply or tributary
to a surface water supply.
The system has a septic tank and SAS and the SAS is within Zone I of a public water supply well.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm.Method used to determine distance (approximation not valid).
3) OTHER
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 2 Blackberry Lane,Hyannis MA 02601
Owner: Michelle Maher
Date of Inspection:01/15/05
D) SYSTEM FAILS
You must indicate either"Yes"or"No"to each of the fallowing:
I Hve determined that one or more of the following failure conditions exist as describbed in 310 CMR 15.303.The basis for
this determination is identified below.The Board of Heath should be contacted to determine what will be necessary to correct the
failure.
Yes No
X Backup of sewage into facility or system component due to an overloaded or cloOgged SAS or cesspool.
_X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below invert or available is less than 1/2 day floew.
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped . , .,—,
X Any portion of the SAS,cesspool or privy is below the high groundwater elevation.
X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion ofa cesspool or privy is within Zone 1 ofa public well.
X Any portion of cesspool or privy is within 50 feet of private water supply well
_ X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for
coliform bacteria,volatile organic compo4nds,ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
The following criteria apply to large systems in addition to the criteria above:
_ The system serves a facility with a design floe of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the folloeing conditions exist:P
Yes No
the system is within 400 feet of surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of
a public water supply well.
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2).Please consult the Iccal
regional office of the Department for further information.
Page 4 of 11
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 2 Blackberry Lane,Hyannis MA 02601
Owner: Michelle Maher
Date of Inspection:O1/15/05
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health.
X _ None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this
inspection.
X _ As built plans have been obtained and examined.Note if they are not available with N/A.
X _ The facility or dwelling was inspected for signs of sewage back-up.
X _ The system does not receive non-sanitary or industrial waste flow.
X _ The site was inspected for signs of breakout.
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X _ All system components,excluding the SAS,have been located on the site.
X _ The septic tank manholes were uncovered,opened;and the interior of the septic tank was inspected for conditions of
baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.
The size and location of the SAS on thesite has been determined based on:
X _ Existing information.For example, Plan at B.OH.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is
X _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of
SubSurface Disposal Systems.
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
j Property Address: 2 Blackberry Lane,Hyannis MA 02601
Owner: Michelle Maher
Date of Inspection:01/15/05
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 110 g.p.d./bedroom
Number of bedrooms(design):3 Number of bedrooms(actual):2
Total DESIGN flow 440 g.o.d.
Number of current residents: 4
Garbage grinder(yes or no): no
Laundry(separate system) (yes or no):no; If yes,separate inspection required
Laundry system inspected(yes or no):
Seasonal use(yes or no):no
Last date of occupancy: 12/04
COMMERCIAL/WDUSTRIAL:
Type of establishment:
Design flow: gp.d.(Based on 1.5.203)
Basis of design flow
Grease trap present:(yes or no)
Non-sanitary waste discharged to the Title 5 system:(yes or no)
Water meter readings,if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped quarterly since 97,acoor ing to owner.
System pumped as part of inspection:(yes or no) no
If yes,volume pumped: gallons
Reason for.pumping:
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other _
APPROXIMATE AGE of all components,date installed(if known)and source of information:House built in 1978,according bo
town records.
Sewage odors detected when arriving at the site:(yes or no) no
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 2 Blackberry Lane,Hyannis MA 02601
Owner: Michelle Maher
Date of Inspection:01/15/05
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction:_cast iron_40 PVC_other(explain)
Distance from water supply well or suction line
Diameter
Comments:(condition of joints,venting,evidence of leakage,etc.)
SEPTIC TANK: x (2 on site,ref.Unit 1 and Unit 2)
(locate on site plan)
Depth below grade: 12" r
Material of construction: x concrete—metal_Fiberglass_Polyethylene_other(explain)
If tank is metal,list age_Is age confirmed by Certificate of Compliance_(Yes/No)
Dimensions: T wide x 11'lone x 6'deep _
Sludge depth: V
Distance from top of sludge to bottom of outlet tee or baffle: 36"
Scum thickness: 0"
Distance from top of scum to bottom of outlet tee or baffle: n/a
How dimensions were determined: Open inspection of interior
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural
integrity,evidence of leakage,etc.)_Upon open inspection of the interior,liquid level is at bottom of outlet invert and no solids are
present No recommendations.
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_Fiberglass_ Polyethylene_other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:_
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
! (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural
integrity,evidence of leakage,etc.)
Page 7 of 1 I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 2 Blackberry Lane,Hyannis MA 02601
Owner: Michelle Maher
Date of Inspection:O1115105
TIGHT OR HOLDING TANK: (Tank must be pumped prior to,or at time of,inspection.)
(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order:Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX: X
(locate on site plan)
Depth of liquid level above outlet invert: 0
Comments:
(not if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) D-box level and
sound.No evidence of solids carryover or leakage into or out of box is present.
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order:(Yes or No)_
Alarms in working order:(Yes or No)_
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 2 Blackberry Lane,Hyannis MA 02601
Owner: Michelle Maher
Date of Inspection:O1/15/05
SOIL ABSORPTION SYSTEM(SAS): x
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
Type:
leaching pits,number: 1
leaching chambers,number:
leaching galleries,number:_
leaching trenches,number,dimensions: _
overflow cesspool,numnber:_
Alternative system:
Name of Technology:
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
All conditions good no recommendations - - -
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CESSPOOLS:_
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert: E
Depth of solids layer: — - - s - - --- - .--
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
Inflow(cesspool must be pumped as part of inspection)
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
PRIVY:_
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 2 Blackberry Lane,Hyannis MA 02601
Owner: Michelle Maher
Date of Inspection:01/15/05
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to at least two permanent reference landmarks or benchmarks
Locate all wells within 100'(Locate where public water supply comes into house)
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62'
83'
0
19'4"
25'8"
Back of house 2 Blackberry Lane
s
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 2 Blackberry Lane,Hyannis MA 02601
Owner: Michelle Maher
Date of Inspection:01/15/05
NRCS Report name
Soil Type
Typical depth to groundwater
USGS Date website visited
Observation Wells checked -
Groundwater depth: Shallow Moderate --Deep
SITE EXAM Slope
Surface water
Check cellar
Shallow wells
Estimated Depth to Groundwater 35 Feet
Please indicate all methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record.
x Observed Site(Abutting property,observation hole,basement sump etc.)
x Determined from local conditions
x Checked with local Board of Health
Checked FEMA Maps
Checked pumping records
x Checked local excavators,installers
Used USGS Data
Describe how you established the High Groundwater Elevation. Must be completed)
Well on-site.
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